Peer Mentor Program – Mentor Connect - Eating Disorders Queensland

INITIAL ASSESSMENT

Estimated completion time is 10-15 minutes.

This form is for individuals seeking treatment for themselves.

If you are a carer/key support person, or looking for treatment for another person, please email [email protected] instead.

Hello, this will be your first step of engaging with Eating Disorders Qld. We acknowledge that it can be difficult to discuss your experiences with eating disorder/s and body image issues, particularly at first.

To make it a bit easier, we have developed this form that you can complete and send back to us before we call you.

You will receive a call to discuss the information provided, or we are happy to complete the form with you. During this call we can discuss any questions or touch on issues pertaining to the questions on the form.

After the phone assessment has been completed and we both feel that EDQ is a good fit one of our practitioners will arrange a more comprehensive ‘intake’ session.

During an intake session, you and the practitioner will review your needs, recovery goals and expectations of therapy/holistic recovery needs. This session takes around 90 minutes.

We will also go through Confidentiality and our shared Rights & Responsibilities. Looking forward to meeting you!

Terms & Conditions

Due to the high demand for EDQ’s funded services, and allowing for fair equitable distribution of therapeutic resources to the community:

• EDQ requires 48 working hours’ notice of cancellation for all appointments

• In the event of 3 late cancellations or no-shows, your practitioner will discuss other support options with you before booking another appointment

EDQ acknowledges recovery and the therapeutic process is not linear. Please discuss any changing needs or barriers with your practitioner so EDQ can best support you and the greater community.

To access services with EDQ, we require that you engage regularly with a GP to monitor your medical stability. As part of this process, a GP will need to sign EDQ’s client medical clearance form. Medical monitoring is required for all clients, no matter what kind of eating disorder behaviour is present. Eating disorders have significant impacts on physical health.

If you do not currently have a suitable GP, please let us know and we can assist you to find one.

I agree to the terms and conditions outlined above, and consent to the information I provide being stored on a secure database and shared within the EDQ team, as necessary.

I will engage regularly with a GP for the purposes of monitoring my medical stability.

Yes No

Date

Title

Family Name

Given Name(s)

Preferred Name

Gender

Male Female Other

If Other, please specify gender

Pronouns

Date of birth

Phone Number

Email

Current Address

Suburb

Postcode

Please identify if any of the following impact your life?

if Other, please specify

What is your proficiency in English?

Do you require an Interpreter/Auslan Connections and/or advocacy service?

No Yes

If Yes, please specify language

Do you need the use of assistive technology?

No Yes

If Yes, please specify technology

Do you have any current literacy/reading issues that you might need assistance with?

No Yes

Are you a current NDIS participant?

No Yes

EDQ strives to be inclusive of diverse groups (Aboriginal and Torres Strait Islander, Culturally and Linguistically Diverse (CALD), religious / spiritual beliefs, gender, sexual orientation, physical and intellectual disability, age and socio-economic status), that access the service. Please let us know if you have any requirements related to this statement, or would like to be given information on other available services that you could also connect with?

Country of birth

Are you of Aboriginal or Torres Strait Islander Origin?

No Yes, Aboriginal Yes, Torres Strait Islander Yes, both Aboriginal and Torres Strait Islander

What cultural background or ethnicity do you identify with?

What is the main language spoken in your home?

Do you identify with the LGBTIQA+ community?

Yes No

If Other, please specify status

What is your main source of income?

Disability Support Pension Other pension or benefit (please specify) Paid employment Compensation payments Other, e.g., superannuation, investments (please specify) No source of income

If Other, please specify source

Who referred you to us at EDQ?

Do you have a current GP Mental Health Treatment Plan?

Yes No

Is it OK for us to identify ourselves as EDQ when we contact you?

Yes No

What is your preferred contact method?

Phone Call Email Text Message (where possible)

Do you want to be on our mailing list (events, education, and updates, including program vacancies)?

Yes No

We will email you a written Consent and Rights and Responsibilities Form for you to review and sign before your Intake Appointment. These documents detail how we handle your information. If you have any queries, feel free to ask any staff member.

Do you have a family member/friend/partner supporting you with your eating disorder?

Yes No

You can invite a support person to your intake appointment if you would find that helpful – just let us know when we book that appointment in.

In approximately which year did you first experience any eating disorder symptoms, including significant concerns about weight and shape?

When did you first reach out for any support for your eating disorder (approximate date). This can be any health professional – it could be your GP, your school counsellor or nurse etc.

If Other, please specify diagnoses

Who was the diagnosis made by?

Doctor (GP) Psychiatrist Other

If Other, please specify whom

When was your first contact with specialist eating disorder treatment/services? This might be EDQ, QuEDS, a psychologist, dietitian etc. – someone who specifically works with eating disorders.

What support have you accessed so far for your Eating Disorder(s)?

If Other, please specify support

How often do you currently engage with your GP?

GP contact details:

To prepare for your intake session with an Eating Disorders Practitioner at EDQ, you may like to consider some of these questions:

What support you have accessed in the past and how it has benefited you?
What support or strategies has worked well for you in the past?
What support are you getting now?
What support you feel you require now?
3 Top Recovery goals